J Prima Med Sains (2023) 5(2):113-119 https://doi.org/10.34012/jpms.v5i2.4069
ORIGINAL ARTICLE
*
Patient experiences in primary health care services in the JKN era: A qualitative study
Hartono1, Masryna Siagian2*, Marlina Elpiani Siahaan3, Ester Theresia Tambunan3, Eva Ellya Sibagariang2
Abstract
Implementing JKN (Jaminan Kesehatan Nasional) in primary healthcare is expected to support the accessibility and success of early treatment and reduce the burden on secondary healthcare facilities. Patient experience can provide information on the quality of health services from different perspectives to provide valuable input for improving the quality of care. This study explores patients' experiences in utilizing health services in primary healthcare services in the JKN era. This research used a qualitative approach with a case study design conducted at the Puskesmas Tangkahan Durian, Langkat Regency. The researchers collected data through oral questioning with 11 informants, following previously developed in-depth interview guidelines. Researchers have also made direct observations of the health services carried out. The study results showed that patients had a fairly positive experience accessing health services at public health center/puskesmas. There was no discrimination or difference in treatment among health workers in JKN patients or general patients. Patient complaints are only in the location of the seats in the waiting room that are not arranged to interfere with patient mobility. Another criticism is that officers do not come to the public health center on time according to predetermined operating hours. Public health center management should increase the discipline of officers regarding service operating hours and consider the seating layout in the patient waiting room.
Keywords: patient experiences, health care services, JKN
Introduction
Since 2014, the Indonesian government implemented the National Health Insurance/Jaminan Kesehatan Nasional (JKN) to protect the entire population. In the JKN era, health services must be carried out according to medical needs. This model is intended to improve the quality of health services.
Puskesmas, or public health centers, are primary health service providers that focus on promotive and preventive functions. Quality health services at the primary level are expected to reduce the number of referrals to advanced health facilities such as hospitals.1,2
The attention of researchers, policymakers, and the public to measure healthcare quality has grown rapidly in recent decades.3.4 Donabedian formulated three types of measures have been formulated that can be used to measure service quality. First, structural measures provide consumers with an overview of healthcare providers' capacity, systems, and processes to deliver high-quality care. Furthermore, process measures show what healthcare providers do to maintain or improve health, whether for healthy people or for those diagnosed with a health condition. Finally, outcome measures reflect the impact of health services or interventions on a patient's health status.5 Donabedian also formulate seven dimensions to measure the quality of health services: effectiveness, efficiency, efficacy, optimality, acceptability, legitimacy, and equity.6 Parasuraman et al.7 offer a method called ServQual that emphasizes measuring five
Affiliation
1Department of Health Environment, Universitas Prima Indonesia
2Department of Public Health Nutrition, Universitas Prima Indonesia
3Undergraduate Programs in Public Health, Universitas Prima Indonesia
quality dimensions: tangibles, responsiveness, reliability, assurance, and empathy. HospitalQual model8 and HEALTHQUAL model9 emerged from the adaptation and development of the ServQual model. Several recent reports encourage quality patient-focused health care, such as assessing patient experiences in interacting with healthcare institutions.10–12
Patient experience can provide information about healthcare quality from different perspectives.
Their positive interactions during treatment will promote better outcomes and patient satisfaction.13,14 The literature says patient experience is recognized as an independent dimension of health care quality.13.15 A systematic review suggested that patient experience was positively associated with clinical effectiveness and patient safety.13 Therefore, it is important for physicians and healthcare managers to improve healthcare quality in patient experience.16 Wong and Haggerty17 mentioned six important dimensions in measuring patient experience in primary health care, namely access, int: accessorization, continuity and coordination, comprehensiveness of services, trust, and Patient-Reported Impacts of Care.
From a preliminary survey conducted by interviewing patients seeking treatment at the Puskesmas Tangkahan Durian, Langkat Regency, it is known that some aspects still need to meet patient expectations and certainly affect the patient's experience to be satisfactory. For example, health workers arrive late according to the operating hours of the public health center, which opens at 08.30 AM. The patient also complained about the lack of cleanliness in the toilet. In addition, patients complain about cases where they have to buy drugs from outside because of the absence of certain medications at the health center.
Based on observations made by directly observing the environment of the public health center, the researchers observed that the examination room was relatively small, making it uncomfortable. From the 2022 patient visit data, it can be seen that as many as 586 (17.03%) of 2,857 people (82.97%) who visited from January to August still use health services independently or publicly. Therefore, this research intends to explore patients' experiences of utilizing health services at public health centers during the JKN era.
Method
This study used a qualitative approach with a case-study design. This type of case study research focuses on understanding the research conducted intensively, in detail, and in-depth on a single individual or institution. This type of research provided descriptive information. Descriptive information is a complete picture of the state of the object under study.18 The research subject becomes an informant who provides the information needed during the research process. In this study, purposive sampling techniques are used, in which researchers determine which informant criteria can be selected as the most suitable, useful, and considered samples that can represent a population. The inclusion criteria consisted of JKN patients who sought treatment for more than one visit, patients aged 17-65 years, and those who were willing to be involved from the beginning to the completion of this study.
Researchers collected data through oral questioning with informants following previously prepared in-depth interview guidelines. Researchers have also conducted direct observations of the research object and recorded the symptoms in the field. To maintain the quality and accuracy of the data, the author triangulated the source and method. Cross-checking data performs source triangulation with facts from other sources, and method triangulation is performed by reviewing the documentation and short observations. The data analysis begins with data reduction and data presentation to the conclusion. This study received ethical approval from the Ethics Committee of Universitas Prima, Indonesia.
Results
The informants in this research were those who possessed the expertise and best understanding of specific issues. There were a total of 11 informants, consisting of 5 patients. Meanwhile, the triangulation informants consisted of one doctor, midwife, nurse, administrative staff, pharmacist, and janitor/cleaning staff.
Table 1. Characteristics of informants
Informant Code Gender Age Education Level Occupation
Informant 1 R01 Male 64 Not Educated Unemployed
Informant2 R02 Female 65 Junior High School Housewife
Informant 3 R03 Male 43 Senior High School Entrepreneur
Informant4 R04 Female 46 Junior High School Housewife
Informant 5 R05 Male 39 Junior High School Driver
Informant 6 T01 Female 35 Bachelor in Medicine General Practitioner/Doctor
Informant 7 T02 Female 54 Diploma III in Nursing Nurse
Informant 8 T03 Female 36 Diploma III in Midwifery Midwife
Informant 9 T04 Female 32 Diploma III in Pharmacy Administrative Staff
Informant 10 T05 Female 27 Diploma III in Pharmacy Pharmacy Staff
Informant 11 T06 Female 55 PGA Cleaning Staff
Waiting time for service
From in-depth interviews with patients regarding the time spent waiting, from taking the queue number until receiving the service, it ranges from 60 minutes to one and a half hours. The patients mentioned that the lengthy waiting time was due to the doctor's late arrival at the public health center.
I came around half of the past eight, and the doctor was scheduled at ten. The examination took 15 minutes. Getting the medication didn't take even 10 minutes." (R02)
"The doctor sometimes takes a long time. Sometimes, the doctor arrives around the half past nine. So, I have to wait another 15 minutes." (R03)
When informants were asked about the common assumption that JKN patients were served longer than general patients were, they stated that there was no difference. The informant only complained about the delay of health workers coming to the health center.
"People say that, but it's not true; it's the same." (R01)
"… here, almost everyone uses BPJS (National Health Insurance). So, I feel like we're all treated the same." (R02)
"… it's the same. If I give feedback, the staff should come a bit quicker. Don't let us patients wait for too long.” (R05)
Based on the observation results, it was found that the first patient who arrived had to wait for approximately one hour until their name was called at the registration counter. The registration staff had not yet reached the community health center during operational hours (at 08:30 local time). The average waiting time for patient services was approximately 5-15 minutes after 09:00 AM, the busiest visiting hour.
However, at 11:00 AM, the waiting time for patients was approximately 3-4 minutes due to fewer patient visits. Furthermore, there was no difference in treatment between patients with and without JKN. The registration staff called patients based on their order of arrival regardless of their insurance status.
Health worker friendliness
The interview results showed that the informants thought that health workers were quite friendly and polite in providing services, and there was no difference in treatment between JKN patients and general patients.
"… they were both friendly and polite. I panicked earlier because of an issue with my BPJS card. My husband and I didn't quite understand, but they assisted us patiently.” (R04)
"… there is no difference. The waiting time is the same, whether you use the public service or BPJS (R05)
"… their response was good. They read their medical records when they were registered. Then, the nurse advises us like this, 'Please, try not to stay up late too often’." (R03)
Researchers also interviewed nurses regarding their responses and actions regarding patient complaints. It can be concluded that officers are responsive to service provision.
"We listen first to what the patient is complaining about, then proceed with the examination to address their concerns. Also, we advise the patient, encouraging them to recover quickly and reminding them to take their medications as prescribed for a speedy recovery." (T03)
Doctor's interpersonal communication
From the interview results, it can be seen that the doctor took special time to communicate with informants about his illness. In addition, informants stated that they received explanations from doctors regarding the medical measures given.
"When I entered the examination room, they immediately asked me to measure my height, weight, and took measurements of my arm circumference (LILA). They had a lot to check during the examination." (R04)
The informant also stated that they received an explanation of the rules for using prescribed drugs and their uses. Doctors also distribute health education to patients to prevent the same disease from reinfecting them.
"… they told me when to take the medication and instructed me to come back if I'm still unwell or run out of medicine." (R01)
"… because I'm sick, the doctor explained that I shouldn't eat certain things, start reducing smoking, drinking coffee, and staying up late.” (R03)
Interviews with triangulation informants also revealed that doctors provide health education to patients, enabling them to take care of their health independently and adopt healthy behaviors.
"... the preventive measures are clear, you know. Because those recommendations are also considered preventive so that the patient's condition doesn't worsen or recur." (T01)
Availability and cleanliness of healthcare facilities
The informants expressed discomfort with the support facilities in the waiting area before receiving the service. However, they found the examination room adequately clean and comfortable.
"It's comfortable overall, but one thing bothering me in the waiting area. The seating arrangement was not well designed. It's difficult to pass through, especially as I'm pregnant. The space is too narrow, and people end up shoulder to shoulder." (R04)
"I have to say, and it's not very comfortable. The seating arrangement is not right. Cleanliness is something that requires attention. Just look at the piled-up items in front of the toilet; it's disturbing."
(R05)
Observations of the available facilities at the Puskesmas indicated that several waiting room chairs were placed improperly, hindering patient movement. Additionally, piles of healthcare equipment were placed at the corners of the room. It is necessary to have dedicated space for storing healthcare equipment that is not in use or will be used shortly. On a positive note, the janitorial staff have been performing their duties well, as evidenced by the cleanliness of the floors and overall room tidiness.
Discussion
JKN is one of the national government programs that aims to provide health insurance maintenance and protection for all participants and their family members.19 Many JKN participants show the high community need for health services. Outpatient services are first-level health services, which are a main concern. The public health center in the JKN system plays a significant role in BPJS participants. If public health center services are good, more BPJS participants will use health services. Still, on the contrary, if the services are inadequate, BPJS participants will not use health services.20
This study concluded that the waiting time for patients to receive services is still not up to standard.
Waiting time is the time that patients use to receive health services, starting from registration, entering the doctor's examination room, and taking drugs at the pharmacy. The waiting time for patients reflects how the public health center performs service tasks tailored to the patient's situation and expectations. Based on the Regulation of the Minister of Health Number 129/Menkes/SK/II/2008, waiting times and examination times that are estimated to be satisfactory or unsatisfactory to patients include when patients come from registering at the counter, queuing, and waiting for a call to the poly to be analyzed and examined by doctors, nurses, and midwives. If it is more than 90 minutes, it is included in the old category, 30-60 minutes is in the medium category, and ≤ 30 minutes is categorized as fast.21 JKN is a program that many patients complain about regarding queue length. Ineffective waiting times for each treatment make many patients dissatisfied.22 Patient dissatisfaction arises because of a gap between patient expectations and the performance of health services they feel while using health services, making the patient experience unpleasant.23 In addition, the discipline of officers will affect the time in providing services to patients so that the services provided will be more effective and efficient. Officer discipline in service is the sincerity of employees in providing services, especially the consistency of working time following applicable regulations.24
The study results showed that health workers were friendly and polite in providing services, and there was no difference in treatment between JKN patients and general patients. Consequently, patients feel the experience of getting assistance from nurses attentively, friendly, ready to be needed at any time, not looking angry, quick to come when called, polite and easy to smile.25 Officers' Courtesy and friendliness are the officers' attitudes and behaviors in providing services to the community in a polite and friendly manner as well as mutual respect and respect.26 Responsive interactions between health workers and patients contribute greatly to the patient experience, where a good relationship between health workers and patients will engender patient trust or credibility in public health center services. Health services are good because officers are friendly, patient, and communicative. Conversely, if the health service is considered bad because the officers are rude, talk to them so badly that they are afraid to bring up the problem.27
Interpersonal communication between doctors and patients was also good in this study. Establishing good communication between doctors and patients will build trust, so that treatment can run optimally and provide good outcomes. In the communication process between doctors and patients, there is an exchange of opinions, information delivery, and changes in attitudes and behavior.28,29 Patients feel safe and secure if their physician does what is best for them. Time in conversations between doctors and patients is necessary and does not rush or be limited by time, which results in doctors having less information about the disease the patient suffers, resulting in misdiagnosis or further action that must be taken. Law No. 29 of 2004 concerning Medical Practice clearly states the rights and obligations of doctors and the rights and obligations of patients, including providing explanations and obtaining information.
Patient rights are human rights derived from basic individual rights in the health sector. Communication between doctors and patients is both important and mandatory. This obligation is associated with the maximum effort made by the doctor to treat his patients. The success of these efforts depends on a doctor's success in obtaining complete information about the patient's disease history and the delivery of information about the management of treatment given by the doctor.30
The cleanliness of the public health center environment can certainly affect the patient's assessment of the experience gained during treatment. Cleanliness and comfort are the conditions under which service
water, sanitation, and hygiene in health facilities can pose health risks and threats to visiting patients.31 Health facilities must be equipped with the required premises for the smooth delivery of services and to ensure continuity of services. Comforts can be described as questions covering room comfort, room cleanliness, layout, toilet cleanliness, etc.
Conclusion
Patients had positive experiences accessing healthcare services at public health centers. There has been no discrimination or differential treatment from the healthcare staff, whether towards JKN patients or general patients. The main complaints of patients are related to poorly arranged seating in the waiting area, which hampers patient mobility. Another concern is that some staff members are not punctual when arriving at the health center, according to the designated operational hours. It is recommended that the management of public health centers address these issues by improving the discipline of staff regarding service operating hours and considering a better arrangement for seating in the patient waiting area.
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